Purpose



Compensation and Pension Record Interchange (CAPRI)CAPRI Compensation and Pension Worksheet Module (CPWM)Templates and AMIE Worksheet Disability Benefits Questionnaires (DBQs)Release NotesPatch: DVBA*2.7*169August 2011Department of Veterans AffairsOffice of Enterprise DevelopmentManagement & Financial SystemsPreface Purpose of the Release Notes The Release Notes document describes the new features and functionality of patch DVBA*2.7*169. (CAPRI CPWM TEMPLATES AND AMIE WORKSHEET DBQs). The information contained in this document is not intended to replace the CAPRI User Manual. The CAPRI User Manual should be used to obtain detailed information regarding specific functionality.Table of Contents TOC \o "2-3" \h \z \t "Heading 1,1" 1.Purpose PAGEREF _Toc300578613 \h 12.Overview PAGEREF _Toc300578614 \h 13.Associated Remedy Tickets & New Service Requests PAGEREF _Toc300578615 \h 14.Defects Fixes PAGEREF _Toc300578616 \h 25.Enhancements PAGEREF _Toc300578617 \h 25.1. CAPRI DBQ Template Modifications PAGEREF _Toc300578618 \h 25.1.2. HEARING LOSS AND TINNITUS (changed from released version ~166) PAGEREF _Toc300578619 \h 25.1.3. HEMIC (Changed from released version ~166) PAGEREF _Toc300578620 \h 45.1.4. KIDNEY CONDITONS (Changed from released version ~163) PAGEREF _Toc300578621 \h 45.1.5. MALE REPRODUCTIVE SYSTEM CONDITIONS (changed from released version ~163) PAGEREF _Toc300578622 \h 65.1.6. PROSTATE CANCER (changed from released version ~163) PAGEREF _Toc300578623 \h 85.1.7. SKIN DISEASES (changed from released version ~172) PAGEREF _Toc300578624 \h 85.2. AMIE DBQ Worksheet Modifications PAGEREF _Toc300578625 \h 95.3. CAPRI Template Defects PAGEREF _Toc300578626 \h 95.4. AMIE Worksheets Defects PAGEREF _Toc300578627 \h 96. Disability Benefits Questionnaires (DBQs) PAGEREF _Toc300578628 \h 106.1. DBQ Hearing Loss and Tinnitus PAGEREF _Toc300578629 \h 106.2. DBQ Hematologic and Lymphatic Conditions, Including Leukemia PAGEREF _Toc300578630 \h 156.3. DBQ Kidney Conditions (Nephrology) PAGEREF _Toc300578631 \h 206.4. DBQ Male Reproductive System Conditions PAGEREF _Toc300578632 \h 256.5. DBQ Prostate Cancer PAGEREF _Toc300578633 \h 326.6. DBQ Skin Diseases PAGEREF _Toc300578634 \h 367. Software and Documentation Retrieval PAGEREF _Toc300578635 \h 427.1 Software PAGEREF _Toc300578636 \h 427.2 User Documentation PAGEREF _Toc300578637 \h 427.3 Related Documents PAGEREF _Toc300578638 \h 42PurposeThe purpose of this document is to provide an overview of the enhancements specifically designedfor Patch DVBA*2.7*169. OverviewThis patch introduces enhancements to the AUTOMATED MED INFO EXCHANGE (AMIE) V 2.7package and the Compensation & Pension Record Interchange (CAPRI) application, Compensation & Pension Worksheet Module (CPWM) in support of modified Compensation and Pension (C&P) Disability Benefit Questionnaires (DBQs).DBQ HEARING LOSS AND TINNITUSDBQ HEMATOLOGIC AND LYMPHATIC CONDITIONS, INCLUDING LEUKEMIADBQ KIDNEY CONDITIONS (NEPHROLOGY)DBQ MALE REPRODUCTIVE SYSTEM CONDITIONSDBQ PROSTATE CANCERDBQ SKIN DISEASESThis patch consists of template defects fixes. A word wrapping issue was identified inthe reporting of the following DBQs. There are no changes to the content required. DBQ AMYOTROPHIC LATERIAL SCLEROSIS (LOU GEHRIG’S DISEASE) DBQ HAIRY CELL AND OTHER B-CELL LEUKEMIAS (formerly DBQ LEUKEMIA Template) DBQ ISCHEMIC HEART DISEASE DBQ PARKINSONS In addition to this patch VBAVACO has approved the renaming of CAPRI DBQ LEUKEMIA to DBQ HAIRY CELL AND OTHER B-CELL LEUKEMIAS to avoid confusion with DBQ HEMATOLOGIC AND LYMPHATIC CONDITIONS, INCLUDING LEUKEMIAquestionnaire.Associated Remedy Tickets & New Service RequestsThere are no Remedy tickets or New Service Requests associated with patch DVBA*2.7*169. Defects FixesThere are defect fixes associated with patch DVBA*2.7*169. A word wrapping issue was reportedwith CAPRI DBQ Templates reports and has been corrected in this patch. Enhancements This section provides an overview of the modifications and primary functionality that will be delivered in Patch DVBA*2.7*169.5.1. CAPRI DBQ Template ModificationsVeterans Benefits Administration Veterans Affairs Central Office (VBAVACO) has approved modifications for the following Disability Benefits Questionnaires:DBQ HEARING LOSS AND TINNITUSDBQ HEMATOLOGIC AND LYMPHATIC CONDITIONS, INCLUDING LEUKEMIADBQ KIDNEY CONDITIONS (NEPHROLOGY)DBQ MALE REPRODUCTIVE SYSTEM CONDITIONSDBQ PROSTATE CANCERDBQ SKIN DISEASES VBAVACO has approved renaming the current "DBQ LEUKEMIA" CAPRI template to "DBQ HAIRY CELL AND OTHER B-CELL LEUKEMIAS", to avoid potential confusion with the "DBQ HEMATOLOGIC AND LYMPHATIC CONDITIONS, INCLUDING LEUKEMIA" templateThis patch includes content changes to the following CAPRI DBQ templates listed below:5.1.2. HEARING LOSS AND TINNITUS (changed from released version ~166)5.1.2.1. Section 1: HEARING LOSS, 1 Objective Findings, the Instructions, the secondsentence was changed to the following: Old version:“Report the decibel value, which ranges from - 10 dB to 105 dB, for each of the frequencies.”New version:“Report the decibel (dB) value, which ranges from - 10 dB to 105 dB, for each of the frequencies.”5.1.2.2. Section 1: HEARING LOSS, 1 Objective Findings, part c has been changed to the following:Old version:c. Validity of puretone test results: FORMCHECKBOX Test results are valid. FORMCHECKBOX Test results are invalid (not indicative of organic hearing loss).New version:c. Validity of puretone test results: FORMCHECKBOX Test results are valid for rating purposes. FORMCHECKBOX Test results are not valid for rating purposes (not indicative of organic hearing loss). 5.1.2.3. Section 1: HEARING LOSS, 1 Objective Findings, part f, (Audiologic Findings) A new selection both Right and Left Ear was added: “Unable to interpret reflexes due to artifact.”5.1.2.4. Section 1: HEARING LOSS, 2 Diagnosis new selections both Right and Left Ear was added:“Conductive hearing loss” and “Mixed hearing loss.”5.1.2.5. Section 2: TINNITUS, 3 Etiology of tinnitus was changed to the following: Old version:a. Tinnitus associated with hearing loss FORMCHECKBOX The Veteran has a diagnosis of hearing loss according to VA criteria, and his or her tinnitus is at least as likely as not (50% probability or greater) a symptom associated with the hearing loss, as tinnitus is known to be a symptom associated with hearing loss FORMCHECKBOX The Veteran’s tinnitus is not likely a symptom associated with Veteran’s hearing loss, as Veteran does not have hearing loss according to VA criteriab. Tinnitus not associated with hearing lossNOTE: Select answer below and provide rationale.The Veteran’s tinnitus is: FORMCHECKBOX At least as likely as not (50% probability or greater) caused by or a result of military noise exposureRationale: _________________ FORMCHECKBOX At least as likely as not (50% probability or greater) due to a known etiology (such as traumatic brain injury)Etiology and rationale: _________________ FORMCHECKBOX Not caused by or a result of military noise exposureRationale: _________________ FORMCHECKBOX Cannot provide a medical opinion regarding the etiology of the Veteran’s tinnitus without resorting tospeculationReason speculation required: ________________________New version:Select answer below and provide rationale where requested: FORMCHECKBOX The Veteran has a diagnosis of clinical hearing loss, and his or her tinnitus is at least as likely as not (50% probability or greater) a symptom associated with the hearing loss, as tinnitus is known to be a symptom associated with hearing loss FORMCHECKBOX Less likely than not (less than 50% probability) a symptom associated with the Veterans hearing lossRationale: ____________________ FORMCHECKBOX At least as likely as not (50% probability or greater) caused by or a result of military noise exposureRationale: _________________ FORMCHECKBOX At least as likely as not (50% probability or greater) due to a known etiology (such as traumatic brain injury)Etiology and rationale: _________________ FORMCHECKBOX Less likely than not (less than 50% probability) caused by or a result of military noise exposureRationale: _________________ FORMCHECKBOX Cannot provide a medical opinion regarding the etiology of the Veteran’s tinnitus without resorting tospeculationReason speculation required: ________________________5.1.3. HEMIC (Changed from released version ~166)5.1.3.1. Section 4 (Anemia and thrombocytopenia), part b, changed the following sentence:Old version:“If the Veteran has thrombocytopenia, select the answer that best represents the Veteran’s condition:”New version: “If yes, check all that apply:”5.1.4. KIDNEY CONDITONS (Changed from released version ~163)5.1.4.1.Section 1 (Diagnosis), the following question has been removed:“If no, provide rationale (e.g., Veteran has never had any known kidney condition(s)):”5.1.4.2. Section 1 (Diagnosis), Made the c in code lower case in all instances of "ICD code" and the d in diagnosis lower case in all instances of "Date of diagnosis."5.1.4.3. Section 1, the following selections have been added to the list of possible diagnoses: FORMCHECKBOX Cholesterol emboli ICD code: ______ Date of diagnosis: ________ FORMCHECKBOX Cystic kidney disease ICD code: ______ Date of diagnosis: _________ FORMCHECKBOX Congenital kidney disorder ICD code: ______ Date of diagnosis: _________ FORMCHECKBOX Other inherited kidney disorder, specify: ICD code: ______ Date of diagnosis:_________5.1.4.4 Section 2 (Medical history) was changed from:Describe the history (including cause, onset and course) of the Veteran’s kidney condition: _______Old version:Describe the history (including cause, onset and course) of the Veteran’s kidney condition (brief summary): _____________________________________________________________________New version:Does the Veteran’s treatment plan include taking continuous medication for the diagnosed condition? FORMCHECKBOX Yes FORMCHECKBOX No List medications taken for the diagnosed condition: ________________________5.1.4.5. Section 3 (Renal dysfunction), the top question is no longer designated part a and the subsequent parts have been re-lettered. In addition the question was changed:Old version:Does the Veteran have renal dysfunction? FORMCHECKBOX Yes FORMCHECKBOX No New version:Does the Veteran have renal dysfunction? (Evidence of renal dysfunction includes either persistent proteinuria, hematuria or GFR < 60 cc/min/1.73m2) FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete the following section:5.1.4.6. Section 3, part b, “Other, describe:” was added to the list of a signs/symptoms.5.1.4.7. Section 4 (Urolithiasis) has been changed to the following:Old version: c. Does the Veteran have kidney, ureteral or bladder calculi? FORMCHECKBOX Yes FORMCHECKBOX No If yes, indicate location (check all that apply) FORMCHECKBOX Kidney FORMCHECKBOX Ureter FORMCHECKBOX Bladder If the Veteran has urolithiasis, complete the following:New version:Does the Veteran now have or has he/she ever had kidney, ureteral or bladder calculi (urolithiasis)? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete the following section:Indicate current/past location of calculi (check all that apply) FORMCHECKBOX Kidney FORMCHECKBOX Ureter FORMCHECKBOX Bladder5.1.4.8. Section 5 (Urinary tract/kidney infection has been changed to the following:Old version:Does the Veteran have a history of recurrent symptomatic urinary tract or kidney infections? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, provide etiology: ___________________________If the Veteran has had recurrent symptomatic urinary tract or kidney infections, indicate all treatment modalities that apply:New version:Does the Veteran have a history of recurrent symptomatic urinary tract or kidney infections? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, complete the following section:Etiology of recurrent urinary tract or kidney infections: ___________________________Indicate all treatment modalities used for recurrent urinary tract or kidney infections (check all that apply):5.1.4.9. Section 6 (Kidney transplant or removal) has been changed to the following:Old version:a. Has the Veteran had a kidney removed? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, provide reason: FORMCHECKBOX Kidney donation FORMCHECKBOX Due to disease FORMCHECKBOX Due to trauma or injury FORMCHECKBOX Other, describe: ________________New version:Has the Veteran had a kidney transplant or removal? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete the following section:a. Has the Veteran had a kidney removed? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, provide reason: FORMCHECKBOX Kidney donation FORMCHECKBOX Due to disease FORMCHECKBOX Due to trauma or injury FORMCHECKBOX Other, describe: ________________5.1.4.10. Section 6 part b question has been changed to the following:Old version If Yes statement:“If yes, date of admission:” New version If yes statement:“If yes, date of transplant:”Old version Date questions statement:“Date of discharge:”New version questions statement:“Name of treatment facility, date of admission and date of discharge for transplant:”5.1.4.11. Section 7 (Tumors and neoplasms), part a, the sentence:“If yes, complete the following:” has been changed:“If yes, complete the following section:”5.1.4.12. Section 9 (Diagnostic testing), an additional sentence has been added to the NOTE:“Provide testing completed appropriate to Veteran’s condition; testing indicated below is not indicated for every kidney condition”5.1.4.13.Section 9, part c, the selection:“Protein (albumin):”has been changed to following:“Proteinuria (albumin):”5.1.4.14.Section 9, part d, was changed to following:Old version:d. Urine microalbumin:Date: ___________ Result: ______________New version:d. Spot urine microalbumin/creatinine: Date: ___________ Result: ______________ 5.1.5. MALE REPRODUCTIVE SYSTEM CONDITIONS (changed from released version ~163)5.1.5.1. Section 1 (Diagnosis), the following question has been removed:“If no, provide rationale (e.g., Veteran has never had any known male reproductive organ conditions):”5.1.5.2.Section 1 (Diagnosis), made the “c” in code lower case in all instances of "ICD code" and the “d” in diagnosis lower case in all instances of "Date of diagnosis"5.1.5.3. Section 2 (Medical History), part b, changed the following sentence:Old version:“List medications:”New version:“List medications taken for the diagnosed condition:”5.1.5.4. A new question was added to section 3 (Voiding dysfunction):“a. Etiology of voiding dysfunction:”5.1.5.5.Section 4 (Urinary tract/kidney infection), the following question has been changed:Old version:“If yes, provide etiology:”New version:“If yes, complete the following section:”5.1.5.6.Section 4, consist of a new question that was added:“a. Etiology of recurrent urinary tract or kidney infections:”5.1.5.7.Section 5 (Erectile dysfunction), the following question “If yes, provide etiology:” has been changed to the following:“If yes, complete the following section:”5.1.5.8.Section 5 the following new question was added:“a. Etiology of erectile dysfunction:”5.1.5.9.Section 6 (Retrograde Ejaculation), the question:“If yes, provide etiology of the retrograde ejaculation:”has been replaced by the following sentence:“If yes, complete the following section:”5.1.5.19.Section 6, the following new question was added:“a. Etiology of retrograde ejaculation:”5.1.5.11. Section 7 (Male reproductive organ infections), the following sentence has been changed;Old version:“If yes, indicate all treatment modalities that apply:”New version:“If yes, indicate all treatment modalities used for chronic epididymitis, epididymo-orchitis or prostatitis (check all that apply):”5.1.5.12.Section 8 (Physical exam), part a, the following selection has been changed:Old version:“Not examined; penis exam not relevant to condition”New version:“Not examined per Veteran’s request; Veteran reports normal anatomy with no penile deformity or abnormality”5.1.5.13.Section 8 (Physical exam), part b, the following selection has been changed:Old version:Not examined; testicular exam not relevant to condition”New version:“Not examined per Veteran’s request; Veteran reports normal anatomy with no testicular deformity or abnormality”5.1.5.14. Section 8 (Physical exam), part c, the following selection has been changed:Old version:“Not examined; epididymis exam not relevant to condition”New version:“Not examined per Veteran’s request; Veteran reports normal anatomy of epididymis with no deformity or abnormality”5.1.5.15.Section 9 (Tumors and neoplasms), the top question is no longer designated as part a, and the remaining subsections have been re-lettered.5.1.5.16.Section 9, under the top question, the following sentence has been changed:Old version:“If yes, complete the following:”New version: “If yes, complete the following section:”5.1.5.17.Section 11 (Diagnostic testing),the following sentence has been added to the NOTE:“When appropriate, provide most recent results. No specific studies are required for this examination.”5.1.5.18.Section 11, part a has been changed to the following:Old versionHas the Veteran had a testicular biopsy to determine the presence of spermatozoa? FORMCHECKBOX Yes FORMCHECKBOX No If yes, were spermatozoa present? FORMCHECKBOX Yes FORMCHECKBOX No Date of biopsy: ________________New versionHas a testicular biopsy been performed? FORMCHECKBOX Yes FORMCHECKBOX No Date of biopsy: ________________Results: FORMCHECKBOX Spermatozoa present FORMCHECKBOX Other, describe: _________________________5.1.6. PROSTATE CANCER (changed from released version ~163) 5.1.6.1.Section 1 (Diagnosis), the following question has been removed: “If no, provide rationale (e.g. Veteran has never had prostate cancer):”5.1.7. SKIN DISEASES (changed from released version ~172)5.1.7.1.Section 2 (Medical History), part c, the following sentence has been removed: “If yes, also complete the Tumors and Neoplasms Questionnaire.”5.2. AMIE DBQ Worksheet ModificationsVBAVACO has approved modifications for the following AMIE –DBQ Worksheets.DBQ HEARING LOSS AND TINNITUSDBQ HEMATOLOGIC AND LYMPHATIC CONDITIONS, INCLUDING LEUKEMIADBQ KIDNEY CONDITIONS (NEPHROLOGY)DBQ MALE REPRODUCTIVE SYSTEM CONDITIONSDBQ PROSTATE CANCERDBQ SKIN DISEASESVBAVACO has approved renaming the current "DBQ LEUKEMIA" AMIE worksheet to "DBQ HAIRY CELL AND OTHER B-CELL LEUKEMIAS", to avoid potential confusion with the "DBQ HEMIC AND LYMPHATIC CONDITIONS INCLUDING LEUKEMIA" worksheet.5.3. CAPRI Template DefectsThe following CAPRI Template defects fixes address a word wrapping issue reported. DBQ HAIRY CELL AND OTHER B-CELL LEUKEMIAS (formerly DBQ LEUKEMIA)DBQ ISCHEMIC HEART DISEASEDBQ PARKINSONS On the DBQ AMYOTROPHIC LATERAL SCLEROSIS (LOU GEHRIG’S DISEASE) template,a defect in section 4.g. has been repaired. The prompt reads “check all that apply”, but only one optioncan be selected. This has been fixed to allow selection of multiple options.5.4. AMIE Worksheets DefectsThere are no AMIE Worksheet defects associated with this patch.6. Disability Benefits Questionnaires (DBQs) The following section illustrates the content of the questionnaires included in Patch DVBA*2.7*169.6.1. DBQ Hearing Loss and Tinnitus1. Objective Findingsa. Puretone thresholds in decibels (air conduction): Instructions: Measure and record puretone threshold values in decibels at the indicated frequencies (air conduction). Report the decibel value, which ranges from - 10 dB to 105 dB, for each of the frequencies.Add a plus behind the decibel value when a maximum value has been reached with a failure of responsefrom the Veteran. In those circumstances where the average includes a failure of response at either themaximum allowable limit (105 dB) or the maximum limits of the audiometer, use this maximum decibelvalue of the failure of response in the puretone threshold average calculation.If the Veteran could not be tested (CNT), enter CNT and state the reason why the Veteran could not betested. Clearly inaccurate, invalid or unreliable test results should not be reported.The puretone threshold at 500 Hz is not used in calculating the puretone threshold average for evaluationpurposes but is used in determining whether or not for VA purposes, hearing impairment reaches thelevel of a disability. The puretone threshold average requires the decibel levels of each of the requiredfrequencies (1000 Hz, 2000 Hz, 3000 Hz, and 4000 Hz) be recorded for the test to be valid fordetermination of a hearing impairment. RIGHT EARABCDEFG500 Hz*1000 Hz2000 Hz3000 Hz4000 Hz6000 Hz8000 HzAvg Hz (B – E)** LEFT EARABCDEFG500 Hz*1000 Hz2000 Hz3000 Hz4000 Hz6000 Hz8000 HzAvg Hz (B – E) ** *The puretone threshold at 500 Hz is not used in determining the evaluation but is used in determining whether or not a ratable hearing loss exists.**The average of B, C, D, and E.***CNT – Could Not Testb. Were there one or more frequency(ies) that could not be tested? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, enter CNT in the box for frequency(ies) that could not be tested, and explain why testing could notbe done: _____________________c. Validity of puretone test results: FORMCHECKBOX Test results are valid. FORMCHECKBOX Test results are invalid (not indicative of organic hearing loss). If invalid, provide reason: d. Speech Discrimination Score (Maryland CNC word list) Instructions on pausing: Examiners should pause when necessary during speech discrimination tests, in order to give the Veteran sufficient time to respond. This will ensure that the test results are based on actual hearing loss rather than on the effects of other problems that might slow a Veteran’s response. There are a variety of problems that might require pausing, for example, the presence of cognitive impairment. It is up to the examiner to determine when to use pausing and the length of the pauses.RIGHT EAR %LEFT EAR %e. Appropriateness of Use of Speech Discrimination Score (Maryland CNC word list) FORMCHECKBOX Use of speech discrimination score is appropriate for this Veteran. FORMCHECKBOX The use of the speech discrimination score is not appropriate for this Veteran because of language difficulties, cognitive problems, inconsistent speech discrimination scores, etc., that make combineduse of puretone average and speech discrimination scores inappropriate.f. Audiologic FindingsSummary of Immittance (Tympanometry) Findings:RIGHT EARLEFT EARAcoustic immittanceNormal FORMCHECKBOX Abnormal FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Ipsilateral Acoustic ReflexesNormal FORMCHECKBOX Abnormal FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Contralateral Acoustic ReflexesNormal FORMCHECKBOX Abnormal FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unable to obtain/maintain seal FORMCHECKBOX FORMCHECKBOX 2. DiagnosisRIGHT EAR FORMCHECKBOX Normal hearing FORMCHECKBOX Conductive hearing lossICD code: _____ FORMCHECKBOX Mixed hearing lossICD code: _____ FORMCHECKBOX Sensorineural hearing loss (in the frequency range of 500-4000 Hz)*ICD code: _____ FORMCHECKBOX Sensorineural hearing loss (in the frequency range of 6000 Hz or higher frequencies) ** ICD code: _____ FORMCHECKBOX Significant changes in hearing thresholds in service***LEFT EAR FORMCHECKBOX Normal hearing FORMCHECKBOX Conductive hearing lossICD code: _____ FORMCHECKBOX Mixed hearing lossICD code: _____ FORMCHECKBOX Sensorineural hearing loss (in the frequency range of 500-4000 Hz)*ICD code: _____ FORMCHECKBOX Sensorineural hearing loss (in the frequency range of 6000 Hz or higher frequencies) ** ICD code: _____ FORMCHECKBOX Significant changes in hearing thresholds in service***NOTES: *The Veteran may have hearing loss at a level that is not considered to be a disability for VA purposes. This can occur when the auditory thresholds are greater than 25 dB at one or more frequencies in the 500-4000 Hz range.** The Veteran may have impaired hearing, but it does not meet the criteria to be considered a disability for VA purposes. For VA purposes, the diagnosis of hearing impairment is based upon testing at frequency ranges of 500, 1000, 2000, 3000, and 4000 Hz. If there is no HL in the 500-4000 Hz range, but there is HL above 4000 Hz, check this box. ***The Veteran may have a significant change in hearing threshold in service, but it does not meet the criteria to be considered a disability for VA purposes. (A significant change in hearing threshold may indicate noise exposure or acoustic trauma.)3. Evidence reviewIn order to provide an accurate medical opinion, the Veteran’s records should be reviewed, if available.Was the Veteran’s VA claims file reviewed? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, list any records that were reviewed but were not included in the Veteran’s VA claims file: _____________________________________________________________________________If no, check all records reviewed as part of this examination: FORMCHECKBOX Military service treatment records FORMCHECKBOX _ Military service personnel records FORMCHECKBOX Military enlistment examination FORMCHECKBOX Military separation examination FORMCHECKBOX Military post-deployment questionnaire FORMCHECKBOX Department of Defense Form 214 Separation Documents FORMCHECKBOX Veterans Health Administration medical records (VA treatment records) FORMCHECKBOX Civilian medical records FORMCHECKBOX Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) FORMCHECKBOX Prior audiology reports FORMCHECKBOX _ Other: ______________________________________ FORMCHECKBOX _ No records were reviewed4. EtiologyIf present, is the Veteran’s hearing loss at least as likely as not (50% probability or greater) caused by or a result of an event in military service? FORMCHECKBOX Yes FORMCHECKBOX NoRationale (Provide rationale for either a yes or no answer): ________________ FORMCHECKBOX Cannot provide a medical opinion regarding the etiology of the Veteran’s hearing loss without resorting to speculationProvide rationale for reason speculation required: ________________________Did hearing loss exist prior to the service? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, was the pre-existing hearing loss aggravated beyond normal progression in military service?Right ear FORMCHECKBOX Yes FORMCHECKBOX NoLeft ear FORMCHECKBOX Yes FORMCHECKBOX NoProvide rationale for both yes or no: ________________________5. Functional impact of hearing lossNOTE: Ask the Veteran to describe in his or her own words the effects of disability (i.e. the current complaint of hearing loss on occupational functioning and daily activities). Document the Veteran’sresponse without opining on the relationship between the functional effects and the level of impairment(audiogram) or otherwise characterizing the response. Do not use handicap scales.Does the Veteran’s hearing loss impact ordinary conditions of daily life, including ability to work? FORMCHECKBOX Yes FORMCHECKBOX No If yes, describe impact in the Veteran’s own words: ________________________6. Remarks, if any, pertaining to hearing loss: SECTION 2: TINNITUS1. Medical history Does the Veteran report recurrent tinnitus? FORMCHECKBOX Yes FORMCHECKBOX NoDate and circumstances of onset of tinnitus: _______________________________2. Evidence reviewIn order to provide an accurate medical opinion, the Veteran’s records should be reviewed, if available.Was the Veteran’s VA claims file reviewed? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, list any records that were reviewed but were not included in the Veteran’s VA claims file: _____________________________________________________________________________If no, check all records reviewed as part of this examination: FORMCHECKBOX Military service treatment records FORMCHECKBOX _ Military service personnel records FORMCHECKBOX Military enlistment examination FORMCHECKBOX Military separation examination FORMCHECKBOX Military post-deployment questionnaire FORMCHECKBOX Department of Defense Form 214 Separation Documents FORMCHECKBOX Veterans Health Administration medical records (VA treatment records) FORMCHECKBOX Civilian medical records FORMCHECKBOX Interviews with collateral witnesses (family and others who have known the Veteran before andafter military service) FORMCHECKBOX Prior audiology reports FORMCHECKBOX _ Other: ______________________________________ FORMCHECKBOX _ No records were reviewed3. Etiology of tinnitusSelect answer below and provide rationale where requested: FORMCHECKBOX The Veteran has a diagnosis of clinical hearing loss, and his or her tinnitus is at least as likely as not(50% probability or greater) a symptom associated with the hearing loss, as tinnitus is known to be a symptom associated with hearing loss FORMCHECKBOX Less likely than not (less than 50% probability) a symptom associated with the Veterans hearing lossRationale: ____________________ FORMCHECKBOX At least as likely as not (50% probability or greater) caused by or a result of military noise exposureRationale: _________________ FORMCHECKBOX At least as likely as not (50% probability or greater) due to a known etiology (such as traumatic brain injury)Etiology and rationale: _________________ FORMCHECKBOX Less likely than not (less than 50% probability) caused by or a result of military noise exposureRationale: _________________ FORMCHECKBOX Cannot provide a medical opinion regarding the etiology of the Veteran’s tinnitus without resorting to speculationReason speculation required: ________________________4. Functional impact of tinnitus NOTE: Ask the Veteran to describe in his or her own words the effects of disability (i.e. the current complaint of tinnitus on occupational functioning and daily activities). Document the Veteran’s response without opining on the relationship between the functional effects and the level of impairment (audiogram) or otherwise characterizing the response. Do not use handicap scales.Does the Veteran’s tinnitus impact ordinary conditions of daily life, including ability to work? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe impact in the Veteran’s own words: ____________________5. Remarks, if any, pertaining to tinnitus: ____________________________________Audiologist/clinician signature: __________________________________________ Date: Audiologist/clinician printed name: _______________________________________ State audiology/examiner license #: _____________ Physician address: ___________________________________ Phone: ________________________Fax: _____________________________NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA’s review of the Veteran’s application.6.2. DBQ Hematologic and Lymphatic Conditions, Including LeukemiaName of patient/Veteran: _____________________________________SSN:Your patient is applying to the U. S. Department of Veterans Affairs (VA) for disability benefits.? VA will consider the information you provide on this questionnaire as part of their evaluation in processing the Veteran’s claim.? 1. DiagnosisDoes the Veteran now have or has he/she ever been diagnosed with a hematologic or lymphatic condition? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, select the Veteran’s condition(s) (check all that apply): FORMCHECKBOX Acute lymphocytic leukemia (ALL) ICD code: ________ Date of diagnosis: _____________ FORMCHECKBOX Acute myelogenous leukemia (AML) ICD code: ________ Date of diagnosis: _____________ FORMCHECKBOX Chronic myelogenous leukemia (CML) ICD code: ________ Date of diagnosis: _____________ FORMCHECKBOX Chronic lymphocytic leukemia (CLL) ICD code: ________ Date of diagnosis: _____________ FORMCHECKBOX Hodgkin’s disease ICD code: ________ Date of diagnosis: _____________ FORMCHECKBOX Non-Hodgkin’s lymphoma ICD code: ________ Date of diagnosis: _____________ FORMCHECKBOX Multiple myeloma ICD code: ________ Date of diagnosis: _____________ FORMCHECKBOX Myelodysplastic syndromeICD code: ________ Date of diagnosis: _____________ FORMCHECKBOX PlasmacytomaICD code: ________ Date of diagnosis: _____________ FORMCHECKBOX Anemia (such as anemia of chronic disease, aplastic anemia, hemolytic anemia, iron or vitamin-deficient anemias, thalassemias, myelophthisic anemia, etc.) ICD code: ________ Date of diagnosis: _____________ FORMCHECKBOX Thrombocytopenia ICD code: ________ Date of diagnosis: _____________ FORMCHECKBOX Polycythemia vera ICD code: ________ Date of diagnosis: _____________ FORMCHECKBOX Sickle cell anemia ICD code: ________ Date of diagnosis: _____________ FORMCHECKBOX Splenectomy ICD code: ________ Date of diagnosis: ____________ FORMCHECKBOX Hairy cell or other B-cell leukemia: If checked, complete Hairy cell and other B-cell leukemiasQuestionnaire in lieu of this Questionnaire. FORMCHECKBOX Other, specify:Other diagnosis #1: _____________ICD code: ____________________ Date of diagnosis: ______________Other diagnosis #2: _____________ICD code: ____________________ Date of diagnosis: ______________Other diagnosis #3: _____________ICD code: ____________________ Date of diagnosis: ______________If there are additional diagnoses that pertain to hematologic or lymphatic conditions, list using above format: ____________________________________________________________2. Medical historya. Describe the history (including onset and course) of the Veteran’s hematologic or lymphatic condition (brief summary):___________________b. Is continuous medication required for control of a hematologic or lymphatic condition, including anemia or thrombocytopenia caused by treatment for a hematologic or lymphatic condition? FORMCHECKBOX Yes FORMCHECKBOX No If yes, list only those medications required for control of the Veteran’s hematologic or lymphatic condition,including anemia or thrombocytopenia caused by treatment for a hematologic or lymphatic condition. Provide the name of the medication and the condition the medication is used to treat: __________________________c. Indicate the status of the primary hematologic or lymphatic condition: FORMCHECKBOX Active FORMCHECKBOX Remission FORMCHECKBOX Not applicable3. Treatmenta. Has the Veteran completed any treatment or is the Veteran currently undergoing any treatment for any hematologicor lymphatic condition, including leukemia? FORMCHECKBOX Yes FORMCHECKBOX No; watchful waiting If yes, indicate type of treatment the Veteran is currently undergoing or has completed (check all that apply): FORMCHECKBOX Treatment completed; currently in watchful waiting status FORMCHECKBOX Bone marrow transplantIf checked, provide: Date of hospital admission and location: __________________________ Date of hospital discharge after transplant: __________________________ FORMCHECKBOX SurgeryIf checked, describe: ___________________Date(s) of surgery: ______________ FORMCHECKBOX Radiation therapy Date of most recent treatment: ___________Date of completion of treatment or anticipated date of completion: _________ FORMCHECKBOX Antineoplastic chemotherapy Date of most recent treatment: ___________Date of completion of treatment or anticipated date of completion: _________ FORMCHECKBOX Other therapeutic procedure If checked, describe procedure: ___________________ Date of most recent procedure: __________ FORMCHECKBOX Other therapeutic treatmentIf checked, describe treatment: ______________________Date of completion of treatment or anticipated date of completion: _________4. Anemia and thrombocytopenia (primary, secondary, idiopathic and immune) Does the Veteran have anemia or thrombocytopenia, including that caused by treatment for a hematologic or lymphatic condition? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete the following: a. Does the Veteran have anemia? FORMCHECKBOX Yes FORMCHECKBOX No If yes, is the anemia caused by treatment for another hematologic or lymphatic condition? FORMCHECKBOX Yes FORMCHECKBOX No If yes, provide the name of the other hematologic or lymphatic condition causing the secondary anemia: _______________________b. Does the Veteran have thrombocytopenia? FORMCHECKBOX Yes FORMCHECKBOX No If yes, is the thrombocytopenia caused by treatment for another hematologic or lymphatic condition? FORMCHECKBOX Yes FORMCHECKBOX No If yes, provide the name of the other hematologic or lymphatic condition causing the secondary thrombocytopenia: __________________________If yes, check all that apply: FORMCHECKBOX Stable platelet count of 100,000 or more FORMCHECKBOX Stable platelet count between 70,000 and 100,000 FORMCHECKBOX Platelet count between 20,000 and 70,000 FORMCHECKBOX Platelet count of less than 20,000 FORMCHECKBOX With active bleeding FORMCHECKBOX Other, describe: ________________c. Does the Veteran have any complications or residuals of treatment requiring transfusion of platelets or red blood cells? FORMCHECKBOX Yes FORMCHECKBOX No If yes, indicate frequency of transfusions in the past 12 months: FORMCHECKBOX None FORMCHECKBOX At least once per year but less than once every 3 months FORMCHECKBOX At least once every 3 months FORMCHECKBOX At least once every 6 weeks5. Findings, signs and symptoms Does the Veteran currently have any findings, signs and symptoms due to a hematologic or lymphaticdisorder or to treatment for a hematologic or lymphatic disorder? FORMCHECKBOX Yes FORMCHECKBOX No If yes, check all that apply: FORMCHECKBOX WeaknessIf checked, describe: ___________________ FORMCHECKBOX Easy fatigabilityIf checked, describe: ___________________ FORMCHECKBOX Light-headedness If checked, describe: ___________________ FORMCHECKBOX Shortness of breathIf checked, describe: ___________________ FORMCHECKBOX Headaches If checked, describe: ___________________ FORMCHECKBOX Dyspnea on mild exertionIf checked, describe: ___________________ FORMCHECKBOX Dyspnea at rest If checked, describe: ___________________ FORMCHECKBOX Tachycardia If checked, describe: ___________________ FORMCHECKBOX SyncopeIf checked, describe: ___________________ FORMCHECKBOX Cardiomegaly FORMCHECKBOX High output congestive heart failure FORMCHECKBOX Other, describe: ________________ 6. Recurring infections Does the Veteran currently have recurring infections attributable to any conditions, complications or residuals of treatment for a hematologic or lymphatic disorder? FORMCHECKBOX Yes FORMCHECKBOX No If yes, indicate frequency of infections over past 12 months: FORMCHECKBOX None FORMCHECKBOX At least once per year but less than once every 3 months FORMCHECKBOX At least once every 3 months FORMCHECKBOX At least once every 6 weeks7. Polycythemia veraDoes the Veteran have polycythemia vera? FORMCHECKBOX Yes FORMCHECKBOX No If yes, check all that apply: FORMCHECKBOX Stable, with or without continuous medication FORMCHECKBOX Requiring phlebotomy FORMCHECKBOX Requiring myelosuppressant treatment FORMCHECKBOX Other, describe: ________________ NOTE: If there are complications due to polycythemia vera such as hypertension, gout, stroke or thromboticdisease, ALSO complete appropriate Questionnaire for each condition.8. Sickle cell anemia Does the Veteran have sickle cell anemia? FORMCHECKBOX Yes FORMCHECKBOX No If yes, check all that apply: FORMCHECKBOX Asymptomatic FORMCHECKBOX In remission FORMCHECKBOX With identifiable organ impairment FORMCHECKBOX Following repeated hemolytic sickling crises with continuing impairment of health FORMCHECKBOX Painful crises several times a year FORMCHECKBOX Repeated painful crises, occurring in skin, joints, bones or any major organs FORMCHECKBOX With anemia, thrombosis and infarction FORMCHECKBOX Symptoms preclude other than light manual labor FORMCHECKBOX Symptoms preclude even light manual labor FORMCHECKBOX Other, describe: ________________9. Other pertinent physical findings, complications, conditions, signs and/or symptomsa. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above?? FORMCHECKBOX Yes FORMCHECKBOX No If yes, are any of the scars painful and/or unstable, or is the total area of all related scars greater than 39 square cm (6 square inches)? FORMCHECKBOX Yes FORMCHECKBOX No If yes, also complete a Scars Questionnaire.b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms? FORMCHECKBOX Yes FORMCHECKBOX No If yes, describe (brief summary): _________________________10. Diagnostic testingIf testing has been performed and reflects Veteran’s current condition, no further testing is required.When appropriate, provide most recent complete blood count.a. Has laboratory testing been performed? FORMCHECKBOX Yes FORMCHECKBOX No If yes, provide results:Hemoglobin (gm/100ml): ____________ Date: _________________Hematocrit: ____________Date: _________________Red blood cell (RBC) count: ____________ Date: _________________White blood cell (WBC) count: ____________ Date: _________________White blood cell differential count: ____________ Date: _________________Platelet count: __________________Date: _________________b. Are there any other significant diagnostic test findings and/or results? FORMCHECKBOX Yes FORMCHECKBOX No If yes, provide type of test or procedure, date and results (brief summary): _________________11. Functional impact Do the Veteran’s hematologic or lymphatic condition(s) impact his or her ability to work? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe impact of each of the Veteran’s hematologic and lymphatic conditions, providing one or more examples: _________________________________ 12. Remarks, if any: ______________________________________________________________Physician signature: __________________________________________ Date: ___Physician printed name: _______________________________________ Medical license #: _____________ Physician address: ___________________________________ Phone: ________________________Fax: _____________________________NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA’s review of the Veteran’s application.6.3. DBQ Kidney Conditions (Nephrology)Name of patient/Veteran: _____________________________________SSN:Your patient is applying to the U. S. Department of Veterans Affairs (VA) for disability benefits.? VA will consider the information you provide on this questionnaire as part of their evaluation in processing the Veteran’s claim.?1. Diagnosis:Does the Veteran now have or has he/she ever been diagnosed with a kidney condition? FORMCHECKBOX Yes FORMCHECKBOX No If yes, indicate diagnoses: (check all that apply) FORMCHECKBOX Diabetic nephropathy ICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Glomerulonephritis ICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Hydronephrosis ICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Interstitial nephritis ICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Kidney transplant ICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Nephrosclerosis ICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Nephrolithiasis ICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Renal artery stenosisICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Ureterolithiasis ICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Neoplasm of the kidneyICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Cholesterol emboli ICD code: ______ Date of diagnosis: ____________ FORMCHECKBOX Cystic kidney disease ICD code: ______ Date of diagnosis: ____________ FORMCHECKBOX Congenital kidney disorder ICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Other inherited kidney disorder, specify: ICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Other kidney condition (specify diagnosis, providing only diagnoses that pertain to kidney conditions.) Other diagnosis #1: ______________ ICD code: _____________________Date of diagnosis: _______________ Other diagnosis #2: ______________ ICD code: _____________________Date of diagnosis: _______________If there are additional diagnoses that pertain to kidney conditions, list using above format: _______ 2. Medical historya. Describe the history (including cause, onset and course) of the Veteran’s kidney condition (brief summary): _____________________________________________________________________________________b. Does the Veteran’s treatment plan include taking continuous medication for the diagnosed condition? FORMCHECKBOX Yes FORMCHECKBOX No List medications taken for the diagnosed condition: ________________________ 3. Renal dysfunction Does the Veteran have renal dysfunction? (Evidence of renal dysfunction includes either persistentproteinuria, hematuria or GFR < 60 cc/min/1.73m2) FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete the following section:a. Does the Veteran require regular dialysis? FORMCHECKBOX Yes FORMCHECKBOX No b. Does the Veteran have any signs or symptoms due to renal dysfunction? FORMCHECKBOX Yes FORMCHECKBOX No If yes, check all that apply: FORMCHECKBOX Proteinuria (albuminuria)If checked, indicate frequency: (check all that apply) FORMCHECKBOX Recurring FORMCHECKBOX Constant FORMCHECKBOX Persistent FORMCHECKBOX Edema (due to renal dysfunction)If checked, indicate frequency: (check all that apply) FORMCHECKBOX Some FORMCHECKBOX Transient FORMCHECKBOX Slight FORMCHECKBOX Persistent FORMCHECKBOX Anorexia (due to renal dysfunction) FORMCHECKBOX Weight loss (due to renal dysfunction)If checked, provide baseline weight (average weight for 2-year period preceding onset of disease): ____________Provide current weight: ________________________ FORMCHECKBOX Generalized poor health due to renal dysfunction FORMCHECKBOX Lethargy due to renal dysfunction FORMCHECKBOX Weakness due to renal dysfunction FORMCHECKBOX Limitation of exertion due to renal dysfunction FORMCHECKBOX Able to perform only sedentary activity, due to persistent edema caused by renal dysfunction FORMCHECKBOX Markedly decreased function other organ systems, especially the cardiovascular system, caused by renal dysfunction If checked, describe: ________________________________ FORMCHECKBOX Other, describe: __________________ c. Does the Veteran have hypertension and/or heart disease due to renal dysfunction or caused by anykidney condition? FORMCHECKBOX Yes FORMCHECKBOX No If yes, also complete the Hypertension and/or Heart Disease Questionnaire as appropriate. 4. UrolithiasisDoes the Veteran now have or has he/she ever had kidney, ureteral or bladder calculi (urolithiasis)? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete the following section:a. Indicate current/past location of calculi (check all that apply) FORMCHECKBOX Kidney FORMCHECKBOX Ureter FORMCHECKBOX Bladder b. Has the Veteran had treatment for recurrent stone formation in the kidney, ureter or bladder? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, indicate treatment: (check all that apply) FORMCHECKBOX Diet therapyIf checked, specify diet and dates of use: ____________ FORMCHECKBOX Drug therapyIf checked, list medication and dates of use: ____________ FORMCHECKBOX Invasive or non-invasive procedures If checked, indicate average number of times per year invasive or non-invasive procedures were required: FORMCHECKBOX 0 to 1 per year FORMCHECKBOX 2 per year FORMCHECKBOX > 2 per yearDate and facility of most recent invasive or non-invasive procedure: ______________c. Does the Veteran have any signs or symptoms due to urolithiasis? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, indicate severity (check all that apply): FORMCHECKBOX No symptoms or attacks of colic FORMCHECKBOX Occasional attacks of colic FORMCHECKBOX Frequent attacks of colic FORMCHECKBOX Causing voiding dysfunction FORMCHECKBOX Requires catheter drainage FORMCHECKBOX Causing infection (pyonephrosis) FORMCHECKBOX Causing hydronephrosis FORMCHECKBOX Causing impaired kidney function FORMCHECKBOX Other, describe: ______________________5. Urinary tract/kidney infectionDoes the Veteran have a history of recurrent symptomatic urinary tract or kidney infections? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, complete the following section: a. Etiology of recurrent urinary tract or kidney infections: ___________________________b. Indicate all treatment modalities used for recurrent urinary tract or kidney infections (check all that apply): FORMCHECKBOX No treatment FORMCHECKBOX Long-term drug therapyIf checked, list medications used and indicate dates for courses of treatment over the past 12 months: ____________________________________ FORMCHECKBOX Hospitalization If checked, indicate frequency of hospitalization: FORMCHECKBOX 1 or 2 per year FORMCHECKBOX > 2 per year FORMCHECKBOX DrainageIf checked, indicate dates when drainage performed over past 12 months: ________________ FORMCHECKBOX Continuous intensive managementIf checked, indicate types of treatment and medications used over past 12 months: ______ FORMCHECKBOX Intermittent intensive managementIf checked, indicate types of treatment and medications used over past 12 months: ______ FORMCHECKBOX Other, describe: ___________________ 6. Kidney transplant or removal Has the Veteran had a kidney transplant or removal? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete the following section:a. Has the Veteran had a kidney removed? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, provide reason: FORMCHECKBOX Kidney donation FORMCHECKBOX Due to disease FORMCHECKBOX Due to trauma or injury FORMCHECKBOX Other, describe: ________________b. Has the Veteran had a kidney transplant? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, date of transplant: __________________Name of treatment facility, dates of admission and date of discharge for transplant: _________________________7. Tumors and neoplasmsa. Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses inthe Diagnosis section? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete the following section: b. Is the neoplasm FORMCHECKBOX Benign FORMCHECKBOX Malignantc. Has the Veteran completed treatment or is the Veteran currently undergoing treatment for a benign or malignant neoplasm or metastases? FORMCHECKBOX Yes FORMCHECKBOX No; watchful waitingIf yes, indicate type of treatment the Veteran is currently undergoing or has completed (check all that apply): FORMCHECKBOX Treatment completed; currently in watchful waiting status FORMCHECKBOX SurgeryIf checked, describe: ___________________Date(s) of surgery: __________ FORMCHECKBOX Radiation therapy Date of most recent treatment: ___________Date of completion of treatment or anticipated date of completion: _________ FORMCHECKBOX Antineoplastic chemotherapy Date of most recent treatment: ___________Date of completion of treatment or anticipated date of completion: _________ FORMCHECKBOX Other therapeutic procedure If checked, describe procedure: ___________________ Date of most recent procedure: __________ FORMCHECKBOX Other therapeutic treatmentIf checked, describe treatment:Date of completion of treatment or anticipated date of completion: _________d. Does the Veteran currently have any residual conditions or complications due to the neoplasm (includingmetastases) or its treatment, other than those already documented in the report above? FORMCHECKBOX Yes FORMCHECKBOX No If yes, list residual conditions and complications (brief summary): ________________e. If there are additional benign or malignant neoplasms or metastases related to any of the diagnoses in theDiagnosis section, describe using the above format: ____________________________________________8. Other pertinent physical findings, complications, conditions, signs and/or symptomsa. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of anyconditions listed in the Diagnosis section above?? FORMCHECKBOX Yes FORMCHECKBOX No If yes, are any of the scars painful and/or unstable, or is the total area of all related scars greater than 39 square cm (6 square inches)? FORMCHECKBOX Yes FORMCHECKBOX No If yes, also complete a Scars Questionnaire.b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms? FORMCHECKBOX Yes FORMCHECKBOX No If yes, describe (brief summary): _________________________9. Diagnostic testingNOTE: If laboratory test results are in the medical record and reflect the Veteran’s current renal function, repeat testing is not required. Provide testing completed appropriate to Veteran’s condition; testing indicated below is not indicated for every kidney condition.a. Has the Veteran had laboratory or other diagnostic studies performed? FORMCHECKBOX Yes FORMCHECKBOX No If yes, provide most recent results, if available:b. Laboratory studies FORMCHECKBOX BUN:Date: ___________ Result: ______________ FORMCHECKBOX Creatinine:Date: ___________ Result: ______________ FORMCHECKBOX EGFR:Date: ___________ Result: ______________ c. Urinalysis: FORMCHECKBOX Hyaline casts:Date: ___________ Result: ______________ FORMCHECKBOX Granular casts:Date: ___________ Result: ______________ FORMCHECKBOX RBC’s/HPF:Date: ___________ Result: ______________ FORMCHECKBOX Proteinuria (albumin):Date: ___________ Result: ______________ FORMCHECKBOX Spot urine for protein/creatinine ratio:Date: ___________ Result: ______________ FORMCHECKBOX 24 hour protein (mg/day):Date: ___________ Result: ______________d. Spot urine microalbumin/creatinine: Date: ___________ Result: ______________e. Are there any other significant diagnostic test findings and/or results? FORMCHECKBOX Yes FORMCHECKBOX No If yes, provide type of test or procedure, date and results (brief summary): _________________10. Functional impact Does the Veteran’s kidney condition(s), including neoplasms, if any, impact his or her ability to work? FORMCHECKBOX Yes FORMCHECKBOX No If yes, describe impact of each of the Veteran’s kidney conditions, providing one or more examples: ____11. Remarks, if any: ______________________________________________________________Physician signature: __________________________________________ Date: ___Physician printed name: _______________________________________ Medical license #: _____________ Physician address: ___________________________________ Phone: ________________________Fax: _____________________________NOTE: VA may request additional medical information, including additional examinations if necessary tocomplete VA’s review of the Veteran’s application.6.4. DBQ Male Reproductive System ConditionsName of patient/Veteran: _____________________________________SSN:Your patient is applying to the U. S. Department of Veterans Affairs (VA) for disability benefits.? VA will consider the information you provide on this questionnaire as part of their evaluation in processing the Veteran’s claim.?1. Diagnosis:Does the Veteran now have or has he ever been diagnosed with any conditions of the male reproductive system? FORMCHECKBOX Yes FORMCHECKBOX No If yes, indicate diagnoses: (check all that apply) FORMCHECKBOX Erectile dysfunction ICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Penis, deformity (e.g., Peyronie’s)ICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Testis, atrophy, one or bothICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Testis, removal, one or bothICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Epididymitis, chronicICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Epididymo-orchitis, chronicICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Prostate injuryICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Prostate hypertrophy (BPH)ICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Prostatitis, chronicICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Prostate surgical residuals (as addressed in items 3-6)ICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Neoplasms of the male reproductive systemICD code: ______Date of diagnosis: ____________ FORMCHECKBOX Other male reproductive system condition (specify diagnosis, providing only diagnoses that pertain to male reproductive system.) ICD code: ______Date of diagnosis: ____________Other diagnosis #1: ______________ ICD code: _____________________Date of diagnosis: _______________ Other diagnosis #2: ______________ ICD code: _____________________Date of diagnosis: _______________If there are additional diagnoses that pertain to the male reproductive organ conditions, list using aboveformat: _______________________________________________________________________________ 2. Medical historya. Describe the history (including onset and course) of the Veteran’s male reproductive organ condition(s)(brief summary): ____________________________________b. Does the Veteran’s treatment plan include taking continuous medication for the diagnosed condition? FORMCHECKBOX Yes FORMCHECKBOX No List medications taken for the diagnosed condition: ________________________c. Has the Veteran had an orchiectomy? FORMCHECKBOX Yes FORMCHECKBOX No Indicate testicle removed: FORMCHECKBOX Right FORMCHECKBOX Left FORMCHECKBOX BothIndicate reason for removal: FORMCHECKBOX Undescended FORMCHECKBOX Congenitally underdeveloped FORMCHECKBOX Other, provide reason for removal: _________________3. Voiding dysfunction Does the Veteran have a voiding dysfunction? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete the following section: a. Etiology of voiding dysfunction: ________________b. Does the voiding dysfunction cause urine leakage? FORMCHECKBOX Yes FORMCHECKBOX No Indicate severity (check one): FORMCHECKBOX Does not require the wearing of absorbent material FORMCHECKBOX Requires absorbent material which must be changed less than 2 times per day FORMCHECKBOX Requires absorbent material which must be changed 2 to 4 times per day FORMCHECKBOX Requires absorbent material which must be changed more than 4 times per day FORMCHECKBOX Other, describe: ____________________c. Does the voiding dysfunction require the use of an appliance? FORMCHECKBOX Yes FORMCHECKBOX No If yes, describe the appliance: ____________________________________________________________d. Does the voiding dysfunction cause increased urinary frequency? FORMCHECKBOX Yes FORMCHECKBOX No If yes, check all that apply: FORMCHECKBOX Daytime voiding interval between 2 and 3 hours FORMCHECKBOX Daytime voiding interval between 1 and 2 hours FORMCHECKBOX Daytime voiding interval less than 1 hour FORMCHECKBOX Nighttime awakening to void 2 times FORMCHECKBOX Nighttime awakening to void 3 to 4 times FORMCHECKBOX Nighttime awakening to void 5 or more timese. Does the voiding dysfunction cause signs or symptoms of obstructed voiding? FORMCHECKBOX Yes FORMCHECKBOX No If yes, check all that apply: FORMCHECKBOX HesitancyIf checked, is hesitancy marked? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Slow or weak streamIf checked, is stream markedly slow or weak? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Decreased force of streamIf checked, is force of stream markedly decreased? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Stricture disease requiring dilatation 1 to 2 times per year FORMCHECKBOX Stricture disease requiring periodic dilatation every 2 to 3 months FORMCHECKBOX Recurrent urinary tract infections secondary to obstruction FORMCHECKBOX Uroflowmetry peak flow rate less than 10 cc/sec FORMCHECKBOX Post void residuals greater than 150 cc FORMCHECKBOX Urinary retention requiring intermittent catheterization FORMCHECKBOX Urinary retention requiring continuous catheterization FORMCHECKBOX Other, describe: _______________________4. Urinary tract/kidney infectionDoes the Veteran have a history of recurrent symptomatic urinary tract or kidney infections? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, complete the following section: a. Etiology of recurrent urinary tract or kidney infections: ___________________________b. Indicate all treatment modalities used for recurrent urinary tract or kidney infections (check all that apply): FORMCHECKBOX No treatment FORMCHECKBOX Long-term drug therapyIf checked, list medications used and indicate dates for courses of treatment over the past 12 months: ____________________________________ FORMCHECKBOX Hospitalization If checked, indicate frequency of hospitalization: FORMCHECKBOX 1 or 2 per year FORMCHECKBOX >2 per year FORMCHECKBOX DrainageIf checked, indicate dates when drainage performed over past 12 months: ________________ FORMCHECKBOX Continuous intensive managementIf checked, indicate types of treatment and medications used over past 12 months: ______ FORMCHECKBOX Intermittent intensive managementIf checked, indicate types of treatment and medications used over past 12 months: ______ FORMCHECKBOX Other, describe: ___________________5. Erectile dysfunction Does the Veteran have erectile dysfunction? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, complete the following section: a. Etiology of erectile dysfunction: ___________________________b. If the Veteran has erectile dysfunction, is it as likely as not (at least a 50% probability) attributable to one of the diagnoses in Section 1, including residuals of treatment for this diagnosis? FORMCHECKBOX Yes FORMCHECKBOX No If yes, specify the diagnosis to which the erectile dysfunction is as likely as not attributable: ___________________c. If the Veteran has erectile dysfunction, is he able to achieve an erection sufficient for penetration andejaculation (without medication)? FORMCHECKBOX Yes FORMCHECKBOX No If no, is the Veteran able to achieve an erection sufficient for penetration and ejaculation (with medication)? FORMCHECKBOX Yes FORMCHECKBOX No6. Retrograde ejaculation Does the Veteran have retrograde ejaculation? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, complete the following section: a. Etiology of retrograde ejaculation: ___________________________b. If the Veteran has retrograde ejaculation, is it as likely as not (at least a 50% probability) attributable to one of the diagnoses in Section 1, including residuals of treatment for this diagnosis? FORMCHECKBOX Yes FORMCHECKBOX No If yes, specify the diagnosis to which the retrograde ejaculation is as likely as not attributable: ___________________7. Male reproductive organ infectionsDoes the Veteran have a history of chronic epididymitis, epididymo-orchitis or prostatitis? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, indicate all treatment modalities used for chronic epididymitis, epididymo-orchitis or prostatitis (check all that apply): FORMCHECKBOX No treatment FORMCHECKBOX Long-term drug therapyIf checked, list medications used and indicate dates for courses of treatment over the past 12 months: ____________________________________ FORMCHECKBOX Hospitalization If checked, indicate frequency of hospitalization: FORMCHECKBOX 1 or 2 per year FORMCHECKBOX > 2 per year FORMCHECKBOX Continuous intensive managementIf checked, indicate types of treatment and medications used over past 12 months: ______ FORMCHECKBOX Intermittent intensive managementIf checked, indicate types of treatment and medications used over past 12 months: ______ FORMCHECKBOX Other, describe: ___________________8. Physical exama. Penis FORMCHECKBOX Normal FORMCHECKBOX Not examined per Veteran’s request FORMCHECKBOX Not examined per Veteran’s request; Veteran reports normal anatomy with no penile deformity or abnormality FORMCHECKBOX Not examined; penis exam not relevant to condition FORMCHECKBOX Abnormal If abnormal, indicate severity: FORMCHECKBOX Loss/removal of half or more of penis FORMCHECKBOX Loss/removal of glans penis FORMCHECKBOX Penis deformity (such as Peyronie’s disease)If checked, describe: ___________b. Testes FORMCHECKBOX Normal FORMCHECKBOX Not examined per Veteran’s request FORMCHECKBOX Not examined per Veteran’s request; Veteran reports normal anatomy with no testicular deformity or abnormality FORMCHECKBOX Not examined; testicular exam not relevant to condition FORMCHECKBOX Abnormal If abnormal, check all that apply:Right testicle FORMCHECKBOX Size 1/3 or less of normal FORMCHECKBOX Size 1/2 to 1/3 of normal FORMCHECKBOX Considerably harder than normal FORMCHECKBOX Considerably softer than normal FORMCHECKBOX Absent FORMCHECKBOX Other abnormality,Describe: _____________________Left testicle FORMCHECKBOX Size 1/3 or less of normal FORMCHECKBOX Size 1/2 to 1/3 of normal FORMCHECKBOX Considerably harder than normal FORMCHECKBOX Considerably softer than normal FORMCHECKBOX Absent FORMCHECKBOX Other abnormality,Describe: _____________________c. Epididymis FORMCHECKBOX Normal FORMCHECKBOX Not examined per Veteran’s request FORMCHECKBOX Not examined per Veteran’s request; Veteran reports normal anatomy of epididymis with no deformity or abnormality FORMCHECKBOX Not examined; epididymis exam not relevant to condition FORMCHECKBOX Abnormal If abnormal, check all that apply:Right epididymis FORMCHECKBOX Tender to palpation FORMCHECKBOX Other, describe: _________________Left epididymis FORMCHECKBOX Tender to palpation FORMCHECKBOX Other, describe: _________________d. Prostate FORMCHECKBOX Normal FORMCHECKBOX Not examined per Veteran’s request FORMCHECKBOX Not examined; prostate exam not relevant to condition FORMCHECKBOX Abnormal If abnormal, describe: _________________9. Tumors and neoplasmsDoes the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete the following section: a. Is the neoplasm FORMCHECKBOX Benign FORMCHECKBOX Malignantb. Has the Veteran completed treatment or is the Veteran currently undergoing treatment for a benign ormalignant neoplasm or metastases? FORMCHECKBOX Yes FORMCHECKBOX No; watchful waitingIf yes, indicate type of treatment the Veteran is currently undergoing or has completed (check all that apply): FORMCHECKBOX Treatment completed; currently in watchful waiting status FORMCHECKBOX SurgeryIf checked, describe: ___________________Date(s) of surgery: __________ FORMCHECKBOX Radiation therapy Date of most recent treatment: ___________Date of completion of treatment or anticipated date of completion: _________ FORMCHECKBOX Antineoplastic chemotherapy Date of most recent treatment: ___________Date of completion of treatment or anticipated date of completion: _________ FORMCHECKBOX Other therapeutic procedure If checked, describe procedure: ___________________ Date of most recent procedure: __________ FORMCHECKBOX Other therapeutic treatmentIf checked, describe treatment:Date of completion of treatment or anticipated date of completion: _________c. Does the Veteran currently have any residual conditions or complications due to the neoplasm (includingmetastases) or its treatment, other than those already documented in the report above? FORMCHECKBOX Yes FORMCHECKBOX No If yes, list residual conditions and complications (brief summary): ________________d. If there are additional benign or malignant neoplasms or metastases related to any of the diagnoses in the Diagnosis section, describe using the above format: ____________________________________________10. Other pertinent physical findings, complications, conditions, signs and/or symptomsa. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of anyconditions listed in the Diagnosis section above?? FORMCHECKBOX Yes FORMCHECKBOX No If yes, are any of the scars painful and/or unstable, or is the total area of all related scars greater than 39 square cm (6 square inches)? FORMCHECKBOX Yes FORMCHECKBOX No If yes, also complete a Scars Questionnaire.b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms? FORMCHECKBOX Yes FORMCHECKBOX No If yes, describe (brief summary): _________________________11. Diagnostic testingNOTE: If imaging studies, diagnostic procedures or laboratory testing has been performed and reflects the Veteran’s current condition, provide most recent results; no further studies or testing are required for this examination. When appropriate, provide most recent results. No specific studies are required for this examination.a. Has a testicular biopsy been performed? FORMCHECKBOX Yes FORMCHECKBOX No Date of biopsy: ________________Resutls: FORMCHECKBOX Spermatozoa present FORMCHECKBOX Other, describe: _________________________b. Have any other imaging studies, diagnostic procedures or laboratory testing been performed and are theresults available? FORMCHECKBOX Yes FORMCHECKBOX No If yes, provide type of test or procedure, date and results (brief summary): _________________12. Functional impact Does the Veteran’s male reproductive system condition(s), including neoplasms, if any, impact his ability to work? FORMCHECKBOX Yes FORMCHECKBOX No If yes, describe the impact of each of the Veteran’s male reproductive system condition(s), providing one or more examples:_____________________________ 13. Remarks, if any: ______________________________________________________________Physician signature: __________________________________________ Date: ___Physician printed name: _______________________________________ Medical license #: _____________ Physician address: ___________________________________ Phone: ________________________Fax: _____________________________NOTE: VA may request additional medical information, including additional examinations if necessary tocomplete VA’s review of the Veteran’s application.6.5. DBQ Prostate CancerName of patient/Veteran: _____________________________________SSN: Your patient is applying to the U. S. Department of Veterans Affairs (VA) for disability benefits.? VA will consider the information you provide on this questionnaire as part of their evaluation in processing the Veteran’s claim.? 1. Diagnosis Does the Veteran now have or has he ever been diagnosed with prostate cancer? FORMCHECKBOX Yes FORMCHECKBOX No If yes, provide only diagnoses that pertain to prostate cancer.Diagnosis #1: ____________________ ICD code: _____________________Date of diagnosis: _______________Diagnosis #2: ____________________ICD code: _____________________Date of diagnosis: _______________Diagnosis #3: ____________________ ICD code: _____________________Date of diagnosis: _______________If there are additional diagnoses that pertain to prostate cancer, list using above format: ____________2. Medical history a. Describe the history (including onset and course) of the Veteran’s prostate cancer condition (brief summary): _____________b. Indicate status of disease: FORMCHECKBOX Active FORMCHECKBOX Remission3. TreatmentHas the Veteran completed any treatment for prostate cancer or is the Veteran currently undergoing any treatment for prostate cancer? FORMCHECKBOX Yes FORMCHECKBOX No; watchful waitingIf yes, indicate treatment type(s) (check all that apply): FORMCHECKBOX Treatment completed; currently in watchful waiting status FORMCHECKBOX Surgery FORMCHECKBOX Prostatectomy FORMCHECKBOX Radical prostatectomy FORMCHECKBOX Transurethral resection prostatectomy FORMCHECKBOX Other (describe)______________ FORMCHECKBOX Other surgical procedure (describe): ___________________Date of surgery: __________ FORMCHECKBOX Radiation therapy Date of completion of treatment or anticipated date of completion: _________ FORMCHECKBOX Brachytherapy Date of treatment: __________ FORMCHECKBOX Antineoplastic chemotherapy Date of completion of treatment or anticipated date of completion: _________ FORMCHECKBOX ?? Androgen deprivation therapy (hormonal therapy)Date of completion of treatment or anticipated date of completion: _________ FORMCHECKBOX Other therapeutic procedure and/or treatment (describe): _____________________________Date of procedure: __________Date of completion of treatment or anticipated date of completion: _________4. Voiding dysfunction Does the Veteran have a voiding dysfunction? FORMCHECKBOX Yes FORMCHECKBOX No If yes, provide etiology of voiding dysfunction: ________________If the Veteran has a voiding dysfunction, complete the following questions:a. Does the voiding dysfunction cause urine leakage? FORMCHECKBOX Yes FORMCHECKBOX No Indicate severity (check one): FORMCHECKBOX Does not require the wearing of absorbent material FORMCHECKBOX Requires absorbent material which must be changed less than 2 times per day FORMCHECKBOX Requires absorbent material which must be changed 2 to 4 times per day FORMCHECKBOX Requires absorbent material which must be changed more than 4 times per day FORMCHECKBOX Other, describe: ____________________b. Does the voiding dysfunction require the use of an appliance? FORMCHECKBOX Yes FORMCHECKBOX No If yes, describe the appliance: ___________________________________________________________________c. Does the voiding dysfunction cause increased urinary frequency? FORMCHECKBOX Yes FORMCHECKBOX No If yes, check all that apply: FORMCHECKBOX Daytime voiding interval between 2 and 3 hours FORMCHECKBOX Daytime voiding interval between 1 and 2 hours FORMCHECKBOX Daytime voiding interval less than 1 hour FORMCHECKBOX Nighttime awakening to void 2 times FORMCHECKBOX Nighttime awakening to void 3 to 4 times FORMCHECKBOX Nighttime awakening to void 5 or more timesd. Does the voiding dysfunction cause signs or symptoms of obstructed voiding? FORMCHECKBOX Yes FORMCHECKBOX No If yes, check all that apply: FORMCHECKBOX HesitancyIf checked, is hesitancy marked? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Slow or weak streamIf checked, is stream markedly slow or weak? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Decreased force of streamIf checked, is force of stream markedly decreased? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Stricture disease requiring dilatation 1 to 2 times per year FORMCHECKBOX Stricture disease requiring periodic dilatation every 2 to 3 months FORMCHECKBOX Recurrent urinary tract infections secondary to obstruction FORMCHECKBOX Uroflowmetry peak flow rate less than 10 cc/sec FORMCHECKBOX Post void residuals greater than 150 cc FORMCHECKBOX Urinary retention requiring intermittent catheterization FORMCHECKBOX Urinary retention requiring continuous catheterization FORMCHECKBOX Other, describe: _______________________5. Urinary tract/kidney infectionDoes the Veteran have a history of recurrent symptomatic urinary tract or kidney infections? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, provide etiology: ___________________________If the Veteran has had recurrent symptomatic urinary tract or kidney infections, indicate all treatment modalities that apply: FORMCHECKBOX No treatment FORMCHECKBOX Long-term drug therapyIf checked, list medications used and indicate dates for courses of treatment over the past 12 months: ____________________________________ FORMCHECKBOX Hospitalization If checked, indicate frequency of hospitalization: FORMCHECKBOX 1 or 2 per year FORMCHECKBOX > 2 per year FORMCHECKBOX DrainageIf checked, indicate dates when drainage performed over past 12 months: ________________ FORMCHECKBOX Continuous intensive managementIf checked, indicate types of treatment and medications used over past 12 months: ______ FORMCHECKBOX Intermittent intensive managementIf checked, indicate types of treatment and medications used over past 12 months: ______ FORMCHECKBOX Other, describe: ___________________6. Erectile dysfunction a. Does the Veteran have erectile dysfunction? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, provide etiology: ___________________________b. If the Veteran has erectile dysfunction, is it as likely as not (at least a 50% probability) attributable to one of the diagnoses in Section 1, including residuals of treatment for this diagnosis? FORMCHECKBOX Yes FORMCHECKBOX No If yes, specify the diagnosis to which the erectile dysfunction is as likely as not attributable: ___________________c. If the Veteran has erectile dysfunction, is he able to achieve an erection sufficient for penetration and ejaculation (without medication)? FORMCHECKBOX Yes FORMCHECKBOX No If no, is the Veteran able to achieve an erection sufficient for penetration and ejaculation (with medication)? FORMCHECKBOX Yes FORMCHECKBOX No7. Retrograde ejaculation a. Does the Veteran have retrograde ejaculation? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, provide etiology of the retrograde ejaculation: ___________________________b. If the Veteran has retrograde ejaculation, is it as likely as not (at least a 50% probability) attributable to one of the diagnoses in Section 1, including residuals of treatment for this diagnosis? FORMCHECKBOX Yes FORMCHECKBOX No If yes, specify the diagnosis to which the retrograde ejaculation is as likely as not attributable: ___________________8. Residual conditions and/or complicationsa. Does the Veteran have any other residual conditions and/or complications due to prostate cancer or treatment forprostate cancer? FORMCHECKBOX Yes FORMCHECKBOX No If yes, describe: ________________________________________9. Other pertinent physical findings, complications, conditions, signs and/or symptomsa. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above?? FORMCHECKBOX Yes FORMCHECKBOX No If yes, are any of the scars painful and/or unstable, or is the total area of all related scars greater than 39 square cm (6 square inches)? FORMCHECKBOX Yes FORMCHECKBOX No If yes, also complete a Scars Questionnaire.b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms? FORMCHECKBOX Yes FORMCHECKBOX No If yes, describe (brief summary): _________________________10. Diagnostic testingNOTE: If laboratory test results are in the medical record and reflect the Veteran’s current condition, repeat testing is not required.Are there any significant diagnostic test findings and/or results? FORMCHECKBOX Yes FORMCHECKBOX No If yes, provide type of test or procedure, date and results (brief summary): _________________ 11. Functional impact Does the Veteran’s prostate cancer impact his ability to work? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe the impact of the Veteran’s prostate cancer, providing one or more examples: ______________12. Remarks, if any: ______________________________________________________________Physician signature: __________________________________________ Date: ___Physician printed name: _______________________________________ Medical license #: _____________ Physician address: ___________________________________ Phone: ________________________Fax: _____________________________NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA’s review of the Veteran’s application.6.6. DBQ Skin DiseasesName of patient/Veteran: _____________________________________SSN: ___Your patient is applying to the U. S. Department of Veterans Affairs (VA) for disability benefits.? VA will consider the information you provide on this questionnaire as part of their evaluation in processing the Veteran’s claim.? 1. Diagnosis: Does the Veteran now have or has he/she ever had a skin condition? FORMCHECKBOX Yes FORMCHECKBOX No If yes, provide only diagnoses that pertain to skin conditions. Indicate the category of skin condition, and then provide specific diagnosis in that category (check all that apply): FORMCHECKBOX Dermatitis or eczema Diagnosis: __________________ ICD code: __________ Date of diagnosis: ______________ FORMCHECKBOX Infectious skin conditions (including bacterial, fungal, viral, treponemal and parasitic skin conditions) Diagnosis: __________________ ICD code: __________ Date of diagnosis: ______________ FORMCHECKBOX Bullous disorders Diagnosis: __________________ ICD code: __________ Date of diagnosis: ______________ FORMCHECKBOX Psoriasis ICD code: __________ Date of diagnosis: ______________ FORMCHECKBOX Exfoliative dermatitis (erythroderma) ICD code: __________ Date of diagnosis: ______________ FORMCHECKBOX Cutaneous manifestations of collagen-vascular diseases Diagnosis: __________________ ICD code: __________ Date of diagnosis: ______________ FORMCHECKBOX Papulosquamous skin disorders Diagnosis: __________________ ICD code: __________ Date of diagnosis: ______________ FORMCHECKBOX Vitiligo Diagnosis: __________________ ICD code: __________ Date of diagnosis: ______________ FORMCHECKBOX Keratinization skin disorders Diagnosis: __________________ ICD code: __________ Date of diagnosis: ______________ FORMCHECKBOX Urticaria Diagnosis: __________________ ICD code: __________ Date of diagnosis: ______________ FORMCHECKBOX Primary cutaneous vasculitis FORMCHECKBOX Erythema multiforme ICD code: __________ Date of diagnosis: ______________ FORMCHECKBOX AcneICD code: __________ Date of diagnosis: ______________ FORMCHECKBOX Chloracne ICD code: __________ Date of diagnosis: ______________ FORMCHECKBOX Alopecia ICD code: __________ Date of diagnosis: ______________ FORMCHECKBOX Hyperhidrosis ICD code: __________ Date of diagnosis: ______________ FORMCHECKBOX Tumors and neoplasms of the skin, including malignant melanoma Diagnosis: __________________ ICD code: __________ Date of diagnosis: ______________ FORMCHECKBOX Other skin condition Other diagnosis #1: ________ ICD code: __________ Date of diagnosis: ______________Other diagnosis #2: ________ ICD code: __________ Date of diagnosis: ______________Other diagnosis #3: ________ ICD code: __________ Date of diagnosis: ______________If there are additional diagnoses that pertain to the skin conditions, list using above format: ______________2. Medical Historya. Describe the history (including onset and course) of the Veteran’s skin conditions (brief summary): _______________________________________________________________________________b. Do any of the Veteran’s skin conditions cause scarring or disfigurement of the head, face or neck? FORMCHECKBOX Yes FORMCHECKBOX No If yes, indicate skin condition and describe scarring and/or disfigurement: _____________Also complete the Scars Questionnaire if appropriate.c. Does the Veteran have any benign or malignant skin neoplasms (including malignant melanoma)? FORMCHECKBOX Yes FORMCHECKBOX No d. Does the Veteran have any systemic manifestations due to any skin diseases (such as fever, weight loss or hypoproteinemia associated with skin conditions such as erythroderma)? FORMCHECKBOX Yes FORMCHECKBOX No If yes, describe: _______________________ Also complete additional Questionnaires if appropriate.3. Treatment a. Has the Veteran been treated with oral or topical medications in the past 12 months for any skin condition? FORMCHECKBOX Yes FORMCHECKBOX No If yes, check all that apply: FORMCHECKBOX Systemic corticosteroids or other immunosuppressive medicationsIf checked, list medication(s): ____________________ Specify condition medication used for: _________________________________ Total duration of medication use in past 12 months: FORMCHECKBOX < 6 weeks FORMCHECKBOX 6 weeks or more, but not constant FORMCHECKBOX Constant/near-constant FORMCHECKBOX Antihistamines If checked, list medication(s): ____________________ Specify condition medication used for: _________________________________ Total duration of medication use in past 12 months: FORMCHECKBOX < 6 weeks FORMCHECKBOX 6 weeks or more, but not constant FORMCHECKBOX Constant/near-constant FORMCHECKBOX Immunosuppressive retinoidsIf checked, list medication(s): ____________________ Specify condition medication used for: _________________________________ Total duration of medication use in past 12 months: FORMCHECKBOX < 6 weeks FORMCHECKBOX 6 weeks or more, but not constant FORMCHECKBOX Constant/near-constant FORMCHECKBOX SympathomimeticsIf checked, list medication(s): ____________________ Specify condition medication used for: _________________________________ Total duration of medication use in past 12 months: FORMCHECKBOX < 6 weeks FORMCHECKBOX 6 weeks or more, but not constant FORMCHECKBOX Constant/near-constant FORMCHECKBOX Other oral medicationsIf checked, list medication(s): ____________________ Specify condition medication used for: _________________________________ Total duration of medication use in past 12 months: FORMCHECKBOX < 6 weeks FORMCHECKBOX 6 weeks or more, but not constant FORMCHECKBOX Constant/near-constant FORMCHECKBOX Topical corticosteroidsIf checked, list medication(s): ____________________ Specify condition medication used for: _________________________________Total duration of medication use in past 12 months: FORMCHECKBOX < 6 weeks FORMCHECKBOX 6 weeks or more, but not constant FORMCHECKBOX Constant/near-constant FORMCHECKBOX Other topical medicationsIf checked, list medication(s): ____________________ Specify condition medication used for: _________________________________ Total duration of medication use in past 12 months: FORMCHECKBOX < 6 weeks FORMCHECKBOX 6 weeks or more, but not constant FORMCHECKBOX Constant/near-constantNOTE: If a medication is used for more than one condition, provide names of all conditions, name of medication used for each condition, and frequency of use for each condition: __________________________________b. Has the Veteran had any treatments or procedures other than systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous disorders? FORMCHECKBOX Yes FORMCHECKBOX No If yes, check all that apply: FORMCHECKBOX PUVA (photo-chemotherapy with psoralen and ultraviolet A) treatment If checked, specify condition treated: _________________________________ Date of most recent treatment: _______________Total duration of treatment in past 12 months: FORMCHECKBOX < 6 weeks FORMCHECKBOX 6 weeks or more, but not constant FORMCHECKBOX Constant/near-constant FORMCHECKBOX UVB (ultraviolet B phototherapy) treatment If checked, specify condition treated: _________________________________ Date of most recent treatment: _______________Total duration of treatment in past 12 months: FORMCHECKBOX < 6 weeks FORMCHECKBOX 6 weeks or more, but not constant FORMCHECKBOX Constant/near-constant FORMCHECKBOX Electron beam therapyIf checked, specify condition treated: _________________________________ Date of most recent treatment: _______________Total duration of treatment in past 12 months: FORMCHECKBOX < 6 weeks FORMCHECKBOX 6 weeks or more, but not constant FORMCHECKBOX Constant/near-constant FORMCHECKBOX Intensive light therapyIf checked, specify condition treated: _________________________________ Date of most recent treatment: _______________Total duration of treatment in past 12 months: FORMCHECKBOX < 6 weeks FORMCHECKBOX 6 weeks or more, but not constant FORMCHECKBOX Constant/near-constant FORMCHECKBOX Other treatmentSpecify treatment: __________________________Specify condition treated: _________________________________ Date of most recent treatment: _______________Total duration of treatment in past 12 months: FORMCHECKBOX < 6 weeks FORMCHECKBOX 6 weeks or more, but not constant FORMCHECKBOX Constant/near-constant4. Debilitating and non-debilitating episodesa. Has the Veteran had any debilitating episodes in the past 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis? FORMCHECKBOX Yes FORMCHECKBOX No If yes, specify condition causing debilitating episodes: FORMCHECKBOX urticaria FORMCHECKBOX primary cutaneous vasculitis FORMCHECKBOX erythema multiforme FORMCHECKBOX toxic epidermal necrolysis Describe debilitating episodes (brief summary): ____________________Number of debilitating episodes in past 12 months: FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 or moreCharacteristics of debilitating episodes FORMCHECKBOX Occurred despite ongoing immunosuppressive therapy FORMCHECKBOX Required treatment with intermittent systemic immunosuppressive therapy FORMCHECKBOX Responded to treatment with antihistamines or sympathomimeticsb. Has the Veteran had any non-debilitating episodes of urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis in the past 12 months? FORMCHECKBOX Yes FORMCHECKBOX No If yes, specify condition causing non-debilitating episodes: FORMCHECKBOX urticaria FORMCHECKBOX primary cutaneous vasculitis FORMCHECKBOX erythema multiforme FORMCHECKBOX toxic epidermal necrolysisDescribe episodes (brief summary): ____________________Number of non-debilitating episodes in past 12 months: FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 or moreCharacteristics of non-debilitating episodes FORMCHECKBOX Occurred despite ongoing immunosuppressive therapy FORMCHECKBOX Required treatment with intermittent systemic immunosuppressive therapy FORMCHECKBOX Responded to treatment with antihistamines or sympathomimetics NOTE: If the Veteran’s debilitating and/or non-debilitating episodes are due to more than one condition, providenames of all conditions, indicating severity and frequency of episodes for each condition: _____________________5. Physical exam a. Indicate the Veteran’s visible skin conditions; indicate the approximate total body area and approximate total EXPOSED body area (face, neck and hands) affected on current examination (check all that apply): FORMCHECKBOX Dermatitis Total body area FORMCHECKBOX None FORMCHECKBOX <5% FORMCHECKBOX 5% to <20% FORMCHECKBOX 20% to 40% FORMCHECKBOX > 40% EXPOSED area FORMCHECKBOX None FORMCHECKBOX <5% FORMCHECKBOX 5% to <20% FORMCHECKBOX 20% to 40% FORMCHECKBOX > 40% FORMCHECKBOX Eczema Total body area FORMCHECKBOX None FORMCHECKBOX <5% FORMCHECKBOX 5% to <20% FORMCHECKBOX 20% to 40% FORMCHECKBOX > 40% EXPOSED area FORMCHECKBOX None FORMCHECKBOX <5% FORMCHECKBOX 5% to <20% FORMCHECKBOX 20% to 40% FORMCHECKBOX > 40% FORMCHECKBOX Bullous disorderTotal body area FORMCHECKBOX None FORMCHECKBOX <5% FORMCHECKBOX 5% to <20% FORMCHECKBOX 20% to 40% FORMCHECKBOX > 40% EXPOSED area FORMCHECKBOX None FORMCHECKBOX <5% FORMCHECKBOX 5% to <20% FORMCHECKBOX 20% to 40% FORMCHECKBOX > 40% FORMCHECKBOX PsoriasisTotal body area FORMCHECKBOX None FORMCHECKBOX <5% FORMCHECKBOX 5% to <20% FORMCHECKBOX 20% to 40% FORMCHECKBOX > 40% EXPOSED area FORMCHECKBOX None FORMCHECKBOX <5% FORMCHECKBOX 5% to <20% FORMCHECKBOX 20% to 40% FORMCHECKBOX > 40% FORMCHECKBOX Infections of the skinTotal body area FORMCHECKBOX None FORMCHECKBOX <5% FORMCHECKBOX 5% to <20% FORMCHECKBOX 20% to 40% FORMCHECKBOX > 40% EXPOSED area FORMCHECKBOX None FORMCHECKBOX <5% FORMCHECKBOX 5% to <20% FORMCHECKBOX 20% to 40% FORMCHECKBOX > 40% FORMCHECKBOX Cutaneous manifestations of collagen-vascular diseaseTotal body area FORMCHECKBOX None FORMCHECKBOX <5% FORMCHECKBOX 5% to <20% FORMCHECKBOX 20% to 40% FORMCHECKBOX > 40% EXPOSED area FORMCHECKBOX None FORMCHECKBOX <5% FORMCHECKBOX 5% to <20% FORMCHECKBOX 20% to 40% FORMCHECKBOX > 40% FORMCHECKBOX Papulosquamous disorder Total body area FORMCHECKBOX None FORMCHECKBOX <5% FORMCHECKBOX 5% to <20% FORMCHECKBOX 20% to 40% FORMCHECKBOX > 40% EXPOSED area FORMCHECKBOX None FORMCHECKBOX <5% FORMCHECKBOX 5% to <20% FORMCHECKBOX 20% to 40% FORMCHECKBOX > 40% FORMCHECKBOX The Veteran does not have any of the above listed visible skin conditionsb. For each skin condition, give specific diagnosis and describe appearance and location: _________6. Specific Skin ConditionsIndicate the Veteran’s specific skin conditions and complete all applicable subsequent questions (check all that apply): FORMCHECKBOX Acne or Chloracne If checked, indicate severity and location (check all that apply): FORMCHECKBOX Superficial acne (comedones, papules, pustules, superficial cysts) of any extent FORMCHECKBOX Deep acne (deep inflamed nodules and pus-filled cysts) FORMCHECKBOX Affects less than 40% of face and neck FORMCHECKBOX Affects 40% or more of face and neck FORMCHECKBOX Affects body areas other than face and neck FORMCHECKBOX Vitiligo If checked, indicate areas affected by vitiligo: FORMCHECKBOX Exposed areas affected FORMCHECKBOX No exposed areas affected FORMCHECKBOX Scarring alopecia If checked, indicate percent of scalp affected: FORMCHECKBOX < 20 % FORMCHECKBOX 20 to 40% FORMCHECKBOX > 40% FORMCHECKBOX Alopecia areata If checked, indicate amount of hair loss: FORMCHECKBOX Hair loss limited to scalp and face FORMCHECKBOX Loss of all body hair FORMCHECKBOX Other, describe: ______________________________________ FORMCHECKBOX Hyperhidrosis If checked, indicate severity: FORMCHECKBOX Able to handle paper or tools after treatment FORMCHECKBOX Unresponsive to treatment; unable to handle paper or tools FORMCHECKBOX Veteran does not have any of the specific skin conditions listed above7. Tumors and neoplasmsa. Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in theDiagnosis section? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete the following: b. Is the neoplasm FORMCHECKBOX Benign FORMCHECKBOX Malignantc. Has the Veteran completed treatment or is the Veteran currently undergoing treatment for a benign or malignant neoplasm or metastases? FORMCHECKBOX Yes FORMCHECKBOX No; watchful waitingIf yes, indicate type of treatment the Veteran is currently undergoing or has completed (check all that apply): FORMCHECKBOX Treatment completed; currently in watchful waiting status FORMCHECKBOX SurgeryIf checked, describe: ___________________Date(s) of surgery: __________ FORMCHECKBOX Radiation therapy Date of most recent treatment: ___________Date of completion of treatment or anticipated date of completion: _________ FORMCHECKBOX Antineoplastic chemotherapy Date of most recent treatment: ___________Date of completion of treatment or anticipated date of completion: _________ FORMCHECKBOX Other therapeutic procedure If checked, describe procedure: ___________________ Date of most recent procedure: __________ FORMCHECKBOX Other therapeutic treatmentIf checked, describe treatment: __________Date of completion of treatment or anticipated date of completion: _________d. Does the Veteran currently have any residual conditions or complications due to the neoplasm (including metastases) or its treatment, other than those already documented in the report above? FORMCHECKBOX Yes FORMCHECKBOX No If yes, list residual conditions and complications (brief summary): ________________e. If there are additional benign or malignant neoplasms or metastases related to any of the diagnoses in the Diagnosis section, describe using the above format: ____________________________________________8. Other pertinent physical findings, complications, conditions, signs and/or symptomsDoes the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptomsrelated to any conditions listed in the Diagnosis section above? FORMCHECKBOX Yes FORMCHECKBOX No If yes, describe: ____________________________________________________________________________ 9. Functional impact Do any of the Veteran’s skin conditions impact his or her ability to work? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe impact of each of the Veteran’s skin conditions, providing one or more examples: ___________ 10. Remarks, if any: ______________________________________________________________Physician signature: __________________________________________ Date: ___Physician printed name: _______________________________________ Medical license #: _____________ Physician address: ___________________________________ Phone: ________________________Fax: _____________________________NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA’s review of the Veteran’s application.7. Software and Documentation Retrieval7.1 Software The VistA software is being distributed as a PackMan patch message through the National Patch Module (NPM). The KIDS build for this patch is DVBA*2.7*169. 7.2 User Documentation The user documentation for this patch may be retrieved directly using FTP. The preferred method is to FTP the files from:REDACTED This transmits the files from the first available FTP server. Sites may also elect to retrieve software directly from a specific server as follows:OI&T Field OfficeFTP AddressDirectoryAlbanyREDACTED[anonymous.software]HinesREDACTED[anonymous.software]Salt Lake CityREDACTED[anonymous.software]File NameFormatDescriptionDVBA_27_P169_RN.PDFBinaryRelease Notes????DVBA_27_P169_DBQ_HAIRYCELLLEUKEMIAS_WF.DOCXBinaryWorkflow Document????DVBA_27_P169_DBQ_HEARINGLOSSTINNITUS._WF.DOCXBinaryWorkflow Document????DVBA_27_P169_DBQ_ HEMICANDLYMPHATIC.WF.DOCXBinaryWorkflow Document????DVBA_27_P169_DBQ_KIDNEYCONDITIONS_WF.DOCXBinaryWorkflow Document????DVBA_27_P169_DBQ_MALEREPRODUCTIVE_WF.DOCXBinaryWorkflow Document????DVBA_27_P169_DBQ_PROSTATECANCER_WF.DOCXBinaryWorkflow Document???? 7.3 Related Documents The VistA Documentation Library (VDL) web site will also contain the DVBA*2.7*169 Release Notes and Workflow documents. This web site is usually updated within 1-3 days of the patch release date. The VDL Web address for CAPRI documentation is: and/or changes to the DBQs is communicated by the Disability Examination Management Office(DEMO) through:? ................
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